Experience

MOLINA HEALTHCARE INC

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Vice President Payment Integrity - Fraud, Waste, and Abuse Programs

  • Oct 2017 - Present

  Transformational leader driving operations excellence, regulatory compliance, and client value through systems solutions, business process improvements, and reduction in financial exposure. Led efforts to modernize the Special Investigations Unit and the anti-fraud programs of a multi-state Managed Care Organization. Created cost benefit models, budgets and forecasts for department expansions, capital projects, and cost savings programs. Negotiated and administered contracts, proposals, and oversight programs for audit vendors. Integrated strategic vendors to optimize payment integrity operations and drive regulatory compliance as well as to significantly improve the operation's return on investment. Set key performance indicators and monitoring protocols. Show less



OptumRx - a United Health Group Company

• Irvine, CA

• Vice President Network Audit and Recovery

  • Aug 2006 - Apr 2016

  Led overall network audit strategy and program innovation for Pharmacy Benefits Manager administering over 50 million lives under Medicare Part D, Medicaid, and Commercial pharmacy networks. Led audit operations of a multi-national team of 167 auditors/analysts under $15M budget, conducting both prospective and retrospective audits. Designed financial modeling, cost benefit analysis, budgets and forecasts for department expansions, capital projects, and cost savings programs. Drove audit plan and strategy to assure compliance with governmental regulations and federal/state law. Spearheaded future state of systems and best practice determinations in audit integration for two multi-million member corporate mergers/expansions. Created predictive analytics, data mining algorithms, and investigation techniques, resulting in annual payment integrity recovery increases of up to 50% year over year. Negotiated and administered contracts, proposals, and oversight programs for audit vendors. Monitored that key performance indicators were met. Performed quarterly business reviews with key clients on program results, trends and industry activity. Implemented training and educational programs for executives, clients, and for internal and external regulatory oversight. Collaborated with industry partners, law enforcement and regulatory agencies to combat pharmacy fraud, waste, and abuse Show less



WorkingRx

• Financial Services
• 1 - 100 Employee

• Vice President Business Development

  • Nov 2000 - Jul 2006

  Customized solutions for large national pharmacy chains for workers' compensation claims processing. Responsible for system design and process improvements related to key accounts, business development and valuation activities. Spearheaded strategic account management for largest and most complex pharmacy clients for workers’ compensation and pharmacy third party billing and reconciliation products, representing 56% of corporate volume. Analyzed client business requirements, developed project specs, documented process flows, and designed policy and procedures around new programs. Controlled projects from end-to-end and acted as project liaison between client and functional departments. Prepared request for proposals and sales presentations; prepared and negotiated contracts for major clients. Computed breakeven points on new product development and established base and tiered pricing level. Established internal controls, balancing techniques, and transaction proofs for client accounting and reporting activity. Performed valuations of client accounts receivable balances for purchase of open receivable balances, and forecasted cash flows for projected collections targets. Show less



Price Chopper Supermarkets-Market 32

• United States
• Retail Groceries
• 700 & Above Employee

• Manager Accounting Systems

  • Feb 1990 - Nov 2000

  Led accounting systems installations, implementations, and project oversight including training staff on new systems, interfaces and procedures for supermarket chain. Oversight of accounts receivable and accounts payable teams and financial period close activity and reporting. Prepared monthly consolidated statement of cash flows. Led selection and implementation of an integrated pharmacy chain host system into business, including automation into accounting systems. Developed third party billing and reconciliation controls and balancing protocols, and automated manual claim reconciliation processes. Designed and implemented industry leading DEX\UCS for DSD leading to significant labor savings and automation of store receiving, accounting, and payment practices. Implemented unique RVAS billing and reconciliation system resulting in turning a cost center into a multi-million dollar revenue center. Show less



Charles Marvin and Company, CPA's

• Schenectady/Albany, NY

• Auditor

  • Jun 1987 - Feb 1990